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‘Core competency’ or simply conformity?
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Long as I remember, the rain been comin’ down.
Clouds of myst’ry pourin’, confusion on the ground.
Good men through the ages, tryin’ to find the sun;
And I wonder, still I wonder, who’ll stop the rain?
—“Who’ll Stop the Rain,” Creedence Clearwater Revival (John Fogerty)
The education of the heart — the moral side of man — must keep pace with the education of the head.
Our fellow creatures can not be dealt with as man deals in corn and coal.
— Osler W. Aequanimitas. Philadelphia, Pa.: P. Blakiston’s Son and Co.; 1910.
And if there’s one guiding creed
One word that will sum up
All we would gladly die for
I know that word must surely be
“Individuality”
Hold the line staunch non-conformists
Pay no heed to words of jeer
To you breast clutch tightly your list
Things we’re non-conforming to
This year
— “The Non-Conformist Marching Song,” Neil Diamond
I am trying to get my head around the current state of medicine, and all I seem to accomplish is getting wet. A medical world dominated by conformity is gathering steam. The incorporation of competency-based learning into our medical schools, residency and fellowship programs, and soon into practice is in full-swing. We are already asked to understand and integrate practice-based learning and improvement (PBLI) and systems-based practice (SBP) into our practice lives. I’ve recently written about the enforced conformity of the EMR. Who will stop the rain?
Is competency a goal worthy of our social contract as physicians? Will usurping traditional liberal medical education for competency-based curricula better ensure future physicians become excellent clinicians and, most importantly, prepare our profession to meet patient needs in the future? I worry.
Competency is based on a behaviorist psychological approach to human development. It is a task-based conception familiar to anyone who roamed the halls of a university psychology department in the 1950s and ’60s. As applied to current medical education, it holds that we can take anyone and “train” them as a physician. At its ultimate fruition it is authoritarian, bureaucratic, buzzword driven, and its enormous popularity is scary.
The competency-based model devalues our individuality and our professional status; all part of an unfortunate drift that reflects the corporatization of medical education and education in general. If we truly cared about students as individual students, let alone the future of our profession, would we worship such a foolish paradigm?
William T. Gerson
No one argues against competency in a physician. Competency-based training, however, emphasizes individual skills over the traditional model of the overall learning experience, and in doing so it risks diminishing the role of the medical student and now even the practitioner. Any form of medical education that devalues wisdom will harm the profession and, in the end, patient care.
The new system allows an authority to define the job, establish the training paradigm and assess the competency. There is no longer a profession and, more importantly, no longer an individual professional whose knowledge and wisdom are of value.
The ascension of competency-based education highlights the lemming-like behavior of medical educators. This top-down approach to change in medicine is being driven by the same group of individuals that has attempted to forcibly take over higher-education in general — most often in the form of foundations that exist outside of the academe and the democratic political arena. These foundations are extremely well funded and their influence on policymakers is disproportionately elitist. If modeling our profession on education school drivel isn’t worrisome enough, then to go even further and accept the edicts of self-aggrandizing foundations is downright suicidal.
Perhaps I shouldn’t be surprised. We now have medical schools named for individual donors and children’s hospitals named for financial corporations and insurance companies. My own hospital isn’t even called a hospital, existing over the last several decades as a “health care.” What could diminish the value of physicians and our profession more than these “brandings”?
I’ve always believed that understanding in medicine is an individual expression of knowledge, judgment and experience. It is a creative endeavor, a mode of self-expression unique in each patient encounter and a blend of wisdom and experience. It is the antithesis of the complacency of competence, a system based on the predetermined identification of “benchmarks” and “guidelines.” Medicine, to me, remains an ethical, spiritual and moral obligation that envelopes the physician-patient relationship and is the sine qua non for better outcomes.
The prizing of conformity and not innovation or creativity is apocalyptic. The forces behind competency-based education — by continuing to emphasize the claim of a crippling lack of quality oversight in traditional education — hide a darker motivation: the overthrow of the physician-driven professional, ethical model for one of business … The corn and coal distrusted by Osler. Advocates speak of supposed objective measures of competency when, in fact for medicine, competency is still and always has been subjective. At a most important level there is no objective measure that informs whom you would choose as the physician of a loved one.
Invest in students by investing in teachers. The definition of competencies, even within the now standardized “core competencies” of medicine, can claim the unique status of being both nebulous and rigid, and has become an exercise in futility. Unable to recognize the local definitions of all systems and the subjective nature of professionalism, they are a sham. Worse, they serve as a reason to lengthen training and a move for further subspecialization. And, of course, the possibility that all students should not be able to become physicians is an anathema to the true believers.
For fellow nonconformists, a better model may be the return of apprenticeship and a belief in the value judgments of abilities by the professoriate. We have abdicated our responsibilities to our students, to the profession, to society and to ourselves.
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William T. Gerson, MD, is Clinical Professor of Pediatrics at the University of Vermont College of Medicine and a member of the Infectious Diseases in Children Editorial Board. He can be reached at 52 Timber Lane, S. Burlington, VT 05403; email: William.Gerson@uvm.edu.
Disclosure: Gerson reports no relevant financial disclosures.